Oral Analgesic Requirements Research Articles

WTP7.4 Is there a role for ambulatory management of acute pancreatitis in selected cases?

Abstract Aim Pancreatitis is a common general surgical condition that presents with variable severity. The usual management involves a hospital admission for observation, lasting a median of five days. However, there may be a role for ambulatory management. We aimed to determine which patients presenting with acute pancreatitis may be suitably managed in the community. Method This prospective, multicentre cohort study at 113 UK sites included adult patients diagnosed with pancreatitis. Potential for ambulatory management was defined as the presence of mild pancreatitis, tolerating oral fluids, and oral analgesic requirement only. Multilevel logistic regression models determined relationships, accounting for the clustering of patients within hospitals. Results Of 2580 patients included, only 13 (0.5%) patients were managed without admission and 150 (6.1%) patients were admitted a single night only. Overall 1836 (71%) of patients had mild pancreatitis, of which 928 (50.5%) were potentially suitable for ambulatory care. After accounting for median CRP peak at 48 hours, a CRP of <150 at 48 hours was associated with a lower risk of all complications (OR 0.35, 95% CI 0.30-0.42; P<0.001) and CT-confirmed collection and/or necrosis (0.18, 0.15-0.22; P<0.001). Patients were also twice as likely to be suitable for ambulation (OR 2.07, 1.75-2.44; P<0.001). Conclusion Just over a third of patients with pancreatitis could potentially be managed ambulatory. CRP at 48 hours is a strong predictor of pancreatitis-associated complications and may help direct further follow up.

Minimal effective dose of ultrasound-guided rectus sheath block to reduce oral analgesic requirement after ambulatory laparoscopic tubal resection: a randomized controlled superiority trial

BackgroundThe effective dose during ultrasound-guided rectus sheath block (URSB) for reducing pain after laparoscopic tubal ligation is reported to be 100 mg of 0.25% bupivacaine. We examined the minimal effective dose of 0.25% bupivacaine for URSB on oral analgesic requirement after ambulatory single-port laparoscopic tubal resection.MethodsA prospective, randomized controlled, superiority trial was conducted among patients who had been scheduled for ambulatory laparoscopic tubal resection between September 2015 and January 2019 at a tertiary care hospital in southern Thailand. Anesthesia was induced following protocol. The intervention group was allocated to receive a bilateral URSB using 10 ml of 0.25% bupivacaine on either side after intubation (total 50 mg) while the control group did not receive the sham block. Patients and assessors were blinded to the study intervention. All patients received a multimodal analgesia regimen as follows: fentanyl and ketorolac intraoperatively and fentanyl and oral acetaminophen at the post-anesthetic care unit. Postoperative oral analgesic requirement (acetaminophen and/or ibuprofen) at home was the primary outcome. Postoperative time to first analgesic requirement, oral analgesia (acetaminophen/ibuprofen), and pain score at 6 and 24 h were accessed via telephone interviews. Percentage, effect size (ES), and 95% confidence interval (CI) were presented.ResultsA total of 66 out of 79 eligible patients were analyzed (32 intervention, 34 control). Intraoperative fentanyl consumption was significantly lower in the intervention group (ES [95% CI]: 0.58 [0.08, 1.07] mcg, p = 0.022). Time to first oral analgesia in the intervention group was significantly longer than that of the control group (ES [95% CI]: 0.66 [0.14, 1.16] h, p = 0.012). The proportion of oral analgesia requirement at 24 h after surgery in the control group was significantly higher than that in the intervention group (97% vs 75%, p = 0.012). Pain scores at 6 and 24 h were similar in both groups although slightly lower in the intervention group (ES [95% CI]: 0.22 [−0.26, 0.71], p = 0.368 and 0.33 [−0.16, 0.81], p = 0.184, respectively).ConclusionA dose of 0.25% bupivacaine 50 mg for URSB reduced the oral analgesic requirement at 24 h and prolonged the time to first analgesic requirement after ambulatory laparoscopic tubal resection.Trial registrationThaiclinicaltrials.orgTCTR20150921002. Registered on 18 September 2015

Clinical outcome of transurethral enucleation of the prostate using the 120-W thulium Laser (Vela™ XL) compared to bipolar transurethral resection of the prostate (TURP) in aging male

This study compared the surgical outcomes of the 120-W Thulium laser (Vela™ XL) enucleation of the prostate and bipolar transurethral resection of the prostate (TURP) in terms of efficacy, safety, and improvements of quality of life (QoL) in patients with benign prostate hyperplasia (BPH). Records were obtained from January 2014 to September 2018 for selected patients with symptomatic BPH who underwent 120-W Thulium laser (Vela™XL) prostate enucleation and bipolar TURP in our institution. All the patients selected met the surgical criteria for TURP and had received medical treatment for at least 3 months. Patients were excluded if their ECOG performance status was >1, if they had active malignant disease, of if they had a history of prostate surgery or reconstruction surgery of the urinary system. Patients decided which treatment option would be performed. Both the procedures were conducted by a single surgeon. Clinical outcomes such as changes in the International Prostate Symptom Score (IPSS) score, urodynamic parameters, drug consumption, pain scores, and QoL were evaluated. The rate of urinary tract infection, recatheterization, additional analgesic requirement, return to the emergency department for treatment, and other surgical complications was analyzed and compared between the two cohorts. A total of 276 patients met the inclusion criteria. Among them, 141 patients received bipolar TURP, where as 135 decided to receive laser vaporesection. No significant difference was observed in age, PSA level, prostate volume, and comorbidities between the two cohorts. Pre-operative (pre-op) urodynamic parameters were also identical, except that the laser surgery group had a higher rate of admission with a urinary catheter (24.4% vs. 14.2%, p=0.044). The operating time was longer in the laser surgery group (79.3 minutes vs. 62.4 minutes, p<0.001). However, enucleation using the Thulium laser was superior to bipolar TURP in terms of post-operative (post-op) pain status, including the numeric rating scale of pain, rate of additional narcotic use, and oral analgesic requirement. Compared with bipolar TURP, laser enucleation achieved a higher improvement in the QoL score at post-op follow-up at 2 weeks and 3 months. Nevertheless, the complication rate, changes in IPSS score, Qmax, and post-op medication-free survival were statistically identical in the two cohorts. Our data revealed that compared with bipolar TURP, 120-W Thulium laser (Vela™ XL) enucleation of the prostate achieved lower post-op pain and higher improvement in the short-term QoL of patients after surgery.

Genetic Variations of OPRM1, OPRK1, and COMT Genes and Their Possible Associations with Oral Pain in a Population from Argentina.

To analyze in a population from Argentina the variation of three genes involved in the control of pain pathways-two genes that code for opioid receptors (OPRM1 and OPRK1) and COMT, which codes for an important enzyme in the control of neurotransmission-and to evaluate the associations of these genes with oral pain and the need for analgesics in the population under study. A total of 134 volunteer donors from the city of Resistencia and 27 donors from the Wichí community for comparison were analyzed for 13 single nucelotide polymorphisms (SNPs) and 1 insertion/deletion (Indel) localized in the three genes using polymerase chain reaction-restriction fragment length polymorphism or standard PCR and electrophoresis. All 134 individuals from Resistencia provided biologic samples for DNA analysis, and a subset (n = 81) agreed to answer a questionnaire for an association analysis. Statistical tests for a possible association between genetic variation and self-reported ethnic origin, oral pain, and need for analgesic drugs were performed. Significant differences were found when the study population was compared to populations from other continents, as well as between the two studied populations (P < .05). A positive association was suggested for the COMT gene from Resistencia with both oral pain intensity and analgesic requirements. The admixture process that occurred in the past of Resistencia probably contributed to a genetic differentiation in this population, and this genetic variation might influence phenotypic expressions of pain perception and analgesic requirements.

Randomized controlled trial to compare oral analgesic requirements and patient satisfaction in using oral non-steroidal anti-inflammatory drugs versus benzydamine hydrochloride oral rinses after mandibular third molar extraction: a pilot study.

BackgroundThird molar extraction is associated with considerable pain and discomfort, which is mostly managed with oral analgesic medication. We assessed the analgesic effect of benzydamine hydrochloride, a topical analgesic oral rinse, for controlling postoperative pain following third molar extraction.MethodsA randomized controlled trial was conducted in 40 patients divided into two groups, for extraction of fully erupted third molar. Groups A received benzydamine hydrochloride mouthwash and group B received normal saline gargle with oral ibuprofen and paracetamol. Oral ibuprofen and paracetamol was the rescue analgesic drug in group A. Patients were evaluated on the 3rd and 7th post-operative days (POD) for pain using the visual analogue score (VAS), trismus, total number of analgesics consumed, and satisfaction level of patients.ResultsThe VAS in groups A and B on POD3 and POD7 was 4.55 ± 2.54 and 3.95 ± 1.8, and 1.2 ± 1.64 and 0.95 ± 1.14, respectively and was statistically insignificant. The number of analgesics consumed in groups A and B on POD3 (5.25 ± 2.22 and 6.05 ± 2.43) was not statistically different from that consumed on POD7 (9.15 ± 5.93 and 10.65 ± 6.46). The p values for trismus on POD3 and POD7 were 0.609 and 0.490, respectively and those for patient satisfaction level on POD3 and POD7 were 0.283 and 0.217, respectively.ConclusionsBenzydamine hydrochloride oral rinses do not significantly reduce intake of oral analgesics and are inadequate for pain relief following mandibular third molar extraction.

Factors Predicting Hospital Length of Stay Following Pharyngeal Flap for Velopharyngeal Insufficiency.

Routine hospital admission following pharyngeal flap (PF) to correct velopharyngeal insufficiency (VPI) is the standard at most hospitals. Nevertheless, there is increasing resistance from third-party providers to approve stays longer than a "short stay" (23-hour) observation period. The purpose of the current study was to evaluate length of stay (LOS) and document potential influencing factors following PF. Retrospective chart review. Demographic and perioperative data were collected, and statistical analyses were performed to determine associations with hospital length of stay (LOS). Readiness for discharge was determined by oral intake, analgesic requirement, and respiratory status. Tertiary care children's hospital Participants: All patients undergoing PF for VPI between 1990 and 2014. (1) LOS, (2) % satisfying all discharge criteria within a 23-hour observational time frame. Seventy-five patients were studied, with an average age of 6.8 years. Mean LOS was 65.4 hours. Only 11 patients (14.9%) met all discharge criteria by 23 hours. Multivariate predictors of shorter LOS were increasing patient age, male gender, lack of syndromic association, administration of an intraoperative antiemetic and steroids, and shorter anesthetic duration. Time to first oral intake correlated positively with LOS. Administration of intraoperative antiemetics increased the odds of meeting all discharge criteria within 23 hours by a factor of 12. Identification of factors associated with LOS after PF may allow providers to predict and potentially mitigate hospital stays. Nevertheless, most patients undergoing PF are not clinically ready for discharge within a short-stay (23-hour) observation period.

A critical assessment of the effects of tamsulosin and solifenacin as monotherapies and as a combination therapy for the treatment of ureteral stent-related symptoms: a 2 × 2 factorial randomized trial.

To assess the efficacy of tamsulosin, solifenacin, and combination therapy of both agents for the treatment of ureteral stent-related symptoms (SRSs). An open-label, randomized controlled trial was conducted with 112 patients who underwent unilateral ureteral stent insertion following ureteroscopic stone surgery. Patients were randomized with a 2 × 2 factorial design to one of four groups, i.e., A (control), B (tamsulosin 0.2 mg once daily), C (solifenacin 5 mg once daily), and D (both active treatments). Patients were evaluated at week 2 by the ureteral stent symptom questionnaire (USSQ). The primary efficacy outcome was the urinary symptom score of the USSQ, and the secondary efficacy outcomes were the scores in the other five USSQ domains, the Euro-QOL score, and oral analgesic requirements during the 2 weeks. Efficacy outcomes were primarily analyzed for the per-protocol set population. The four groups were generally well balanced in terms of baseline characteristics. Eighty-one patients (72.3 %) completed the study protocol. Comparison of the six USSQ domain scores at week 2 showed no differences between the four groups. Similarly, comparison of the domain scores stratified by tamsulosin or solifenacin medication showed no differences for either medication. The other secondary outcomes were also similar in the group comparisons. Neither tamsulosin nor solifenacin medications provide beneficial effects for relieving various SRSs. In addition, the combination therapy did not have beneficial effects. Further studies are warranted to determine the benefit of medical therapy for the treatment of SRSs and to determine the optimal management strategy for SRSs.

Laparoscopic verses open appendicectomy

Background:Most commonly performed abdominal surgery is appendicectomy open appendectomy (OA) was introduced by Mc-burney in 1884 still it is the operation of choice in acute appendicitis. Laparoscopic appendectomy (LA) though widely practiced, has not gained universal approval. LA was first described in 1983. Recent studies showed overall benefit in favour of LA. This study is done to view the therapeutic benefit of LA by comparing with conventional OA.Methods: It is a prospective study in 103 patients who underwent appendicectomy in KBN medical college hospital from 15th January 2015 to 15th August 2015. Out of them 60 had conventional OA and 43 had LA. We compared the mean operation time, time of adequate oral feeding, analgesic requirement, and duration of post-operative hospital stay.Results:We found that mean operation time was 33±5.8 minute for open appendicectomy and 47± 7.5 minute for laparoscopic appendicectomy. Duration of post-operative hospital stay was 1.2 days shorter in Laparoscopic group. LA required 1.1 shots of less analgesic than OA. Oral feeding was resumed 21 hours earlier following LA compared to OA. We also found that, in female patient, concurrent ovarian cysts, tubal pregnancy can be diagnosed and managed laparoscopically in the same sitting.Conclusions:Our study found that laparoscopic appendectomy is an effective and safe procedure irrespective sex of the patient. LA has added advantage of early return of bowel movement, less post-op hospital stay and less requirement of analgesic.

Comparison of treatment outcomes according to output voltage during shockwave lithotripsy for ureteral calculi: a prospective randomized multicenter study.

To investigate the effect of fixed versus escalating voltage during SWL on treatment outcomes in patients with ureteral calculi (UC). A prospective, randomized, multicenter trial was conducted on 120 patients who were diagnosed with a single radiopaque UC. The patients were randomized into group C (n = 60, constant 13 kV, 3,000 shock wave, 2 Hz) or group E (n = 60, 11.4-12.0-13 kV per 1,000 shock waves, 2 Hz). They were evaluated by plain abdominal radiography and urinalysis at 1 week after a single session of SWL, and repeat SWL was performed if needed. The primary endpoint was stone-free rate at 1 week (SFR1) after SWL. Secondary endpoints were post-SWL visual pain score (VPS), oral analgesic requirements during 1 week, and cumulative SFRs after the second and third sessions of SWL. Groups C and E were well balanced in terms of baseline patients and stone characteristics, including pre-SWL VPS, stone location, and stone size (6.24 ± 1.92 vs. 6.30 ± 2.13 mm). SFR1s were not significantly different between groups C and E (60.0 vs. 68.3%, p = 0.447). Analyses stratified by stone size (<6 vs. ≥6 mm) showed no difference in SFR1 (p = 0.148 vs. 0.808). In the analyses stratified by stone location, group E tended to be more effective in distal UC (81.0 vs. 50.0%, p = 0.052), whereas no difference was seen in proximal UC (p = 0.487). Secondary endpoints were also similar between the two groups. Our results suggest that voltage escalation during SWL in UC may not provide superior stone fragmentation compared to fixed voltage.

Effect of tamsulosin on stone expulsion in proximal ureteral calculi: an open-label randomized controlled trial

Medical expulsive therapy (MET) using alpha-blockers is effective for distal ureteral calculi (UC). We aimed to evaluate the efficacy of tamsulosin for proximal UC expulsion. An open-label randomized controlled trial was conducted with 108 patients who agreed to conservative management for single, radiopaque, proximal UC ≤ 6 mm and were randomized into group A (n = 54, conservative managements only) or B (n = 54, 0.2 mg tamsulosin once a day). The primary end-point was stone passage rates (SPR) in the intention-to-treat population in 4 treatment weeks. The secondary end-points were estimated in per-protocol population and were time to stone passage, post-trial Euro-quality-of-life (EuroQOL) score, oral analgesic requirements, and willingness to undergo conservative treatment again. The two groups were well balanced in terms of baseline patient and stone characteristics. Seventy nine patients (73.2%; 35 of group A and 44 of group B) completed the study protocol. The overall SPR was 60.2% (65/108). Group B had a higher SPR (74.1%; 40/54) than group A (46.3%; 25/54; p = 0.003) and a significantly shorter time to stone passage (mean days, A: 19.6 vs. B: 14.3, p = 0.005). The groups did not differ in post-trial EuroQOL score or oral analgesic requirements, whereas 74.3% (26/35) of group A and 90.9% (40/44) of group B were willing to undergo conservative treatment again (p = 0.048). Univariate logistic regression analysis showed that stone size (OR = 1.447, p = 0.045) and tamsulosin treatment (OR = 3.314, p = 0.004) significantly predicted stone expulsion. On multivariate analysis, only tamsulosin was statistically significant (OR=3.198, p = 0.021). Tamsulosin was associated with significantly higher stone expulsion rate and shorter expulsion time in proximal UC ≤ 6 mm compared with conservative managements only. Our results indicate that similar to patients with distal UC, MET using tamsulosin is a reasonable treatment option for patients with proximal UC.

Retroperitoneoscopic or laparoscopic adrenalectomy? A single-centre UK experience

Laparoscopic adrenalectomy (LA) is the "gold standard" approach to benign adrenal tumours. Retroperitoneoscopic adrenalectomy (RA) is an increasingly popular alternative. The purpose of this study was to compare our preliminary experience with RA to the more established LA. Data on patients undergoing adrenalectomy over a 2-year period from 2010 were reviewed. Patients undergoing open adrenalectomy, bilateral adrenal surgery, or paraganglioma resection were excluded. The LA and RA patients were compared according to their operative time, time to first oral intake, complications, analgesic requirements, and length of hospital stay. Further analysis was performed on patients matched for all patient and disease-related criteria. Statistical analysis was performed using the χ (2) test and the Mann-Whitney U test as appropriate. A total of 71 adrenalectomies that fit the inclusion criteria were performed during the period studied of which 36 patients underwent LA and 35 patients underwent RA. Mean tumour size differed between the two groups (2.83 cm in RA group vs. 4.1 cm in LA group; p = 0.033). Operative time, time to first oral intake, analgesic requirements, length of hospital stay, and postoperative complications were all significantly lower in the RA group. Analysis of matched patients showed a significant difference between RA and LA in analgesia requirements (5 vs. 8 paracetamol doses, p = 0.014; 2 vs. 10 tramadol doses, p = 0.042) as well as in the length of hospital stay (1.58 vs. 3.58 days, p = 0.038). RA may be associated with reduced postoperative pain and length of hospital stay. It is a valuable alternative to LA in smaller tumours where it may prove to be superior.

Laparoendoscopic single-site surgery (LESS) versus conventional laparoscopic surgery for adnexal preservation: a randomized controlled study

To compare the operative outcomes, postoperative pain, and subsequent convalescence after laparoendoscopic single-site surgery (LESS) or conventional laparoscopic surgery for adnexal preservation. From December 2009 to September 2010, 63 patients underwent LESS (n = 33) or a conventional laparoscopic surgery (n = 30) for cyst enucleation. The overall operative outcomes including postoperative pain measurement using the visual analog scale (VAS) were evaluated (time points 6, 24, and 24 hours). The convalescence data included data obtained from questionnaires on the need for analgesics and on patient-reported time to recovery end points. The preoperative characteristics did not significantly differ between the two groups. The postoperative hemoglobin drop was higher in the LESS group than in the conventional laparoscopic surgery group (P = 0.048). Postoperative pain at each VAS time point, oral analgesic requirement, intramuscular analgesic requirement, and the number of days until return to work were similar in both groups. In adnexa-preserving surgery performed in reproductive-age women, the operative outcomes, including satisfaction of the patients and convalescence after surgery, are comparable for LESS and conventional laparoscopy. LESS may be a feasible and a promising alternative method for scarless abdominal surgery in the treatment of young women with adnexal cysts.

Early Ultrasound‐Guided Neurolysis for Pain Management in Gastrointestinal and Pelvic Malignancies: An Observational Study in a Tertiary Care Center of Urban India

Patients with advanced gastrointestinal and pelvic malignancies commonly present with pain of varying severity. In a majority of these patients, pain can be effectively managed using an integrated systemic pharmacological approach with oral morphine being the cornerstone of treatment. However, with escalating doses, intolerable side effects of oral morphine may lead to patient dissatisfaction. When oral pharmacotherapy fails to adequately address the issue of pain or leads to insufferable side effects, neurolytic blocks of the sympathetic axis are usually used for pain alleviation. As these blocks may reduce oral analgesic requirement, a reevaluation of their timing is merited. This article presents our hospital-based in-patient palliative care unit experience with early ultrasonography-guided neurolysis of celiac plexus, superior hypogastric plexus and ganglion impar. Of the 44 patients we studied, 20 underwent celiac plexus neurolysis, 18 superior hypogastric plexus neurolysis, and 6 ganglion impar neurolysis. Their pain was being managed with oral morphine before neurolysis, but only 11.4% patients required oral morphine for satisfactory pain control, 2 months after neurolysis. The mean Visual Analog Scale score before block placement was 5.64 ± 0.69 and fell to 2.25 ± 1.33 at 2 months post neurolysis (P < 0.001). We suggest that bedside ultrasonography-guided sympathetic axis neurolysis may be employed early in patients with incurable abdominal or pelvic cancer. Its use as a first-line intervention for achieving pain control with minimal complications warrants further consideration and investigation.

Randomized controlled trial of bipolar diathermy vs ultrasonic scalpel for closed hemorrhoidectomy

To compare hemorrhoidectomy with a bipolar electrothermal device or hemorrhoidectomy using an ultrasonically activated scalpel. Sixty patients with grade III or IV hemorrhoids were prospectively randomized to undergo closed hemorrhoidectomy assisted by bipolar diathermy (group 1) or hemorrhoidectomy with the ultrasonic scalpel (group 2). Operative data were recorded, and patients were followed at 1, 3, and 6 wk to evaluate complications. Independent assessors were assigned to obtain postoperative pain scores, oral analgesic requirement and satisfaction scores. Reduced intraoperative blood loss median 0.9 mL (95% CI: 0.8-3.7) vs 4.6 mL (95% CI: 3.8-7.0), P = 0.001 and a short operating time median 16 (95% CI: 14.6-18.2) min vs 31 (95% CI: 28.1-35.3) min, P < 0.0001 was observed in group 1 compared with group 2. There was a trend towards lower postoperative pain scores on day 1 group 1 median 2 (95% CI: 1.8-3.5) vs group 2 median 3 (95% CI: 2.6-4.2), P = 0.135. Reduced oral analgesic requirement during postoperative 24 h after operation median 1 (95% CI: 0.4-0.9) tablet vs 1 (95% CI: 0.9-1.3) tablet, P = 0.006 was observed in group 1 compared with group 2. There was no difference between the two groups in the degree of patient satisfaction or number of postoperative complications. Bipolar diathermy hemorrhoidectomy is quick and bloodless and, although as painful as closed hemorrhoidectomy with the ultrasonic scalpel, is associated with a reduced analgesic requirement immediately after operation.

Infiltration of Wounds and Extraperitoneal Space with Local Anesthetic in Patients Undergoing Laparoscopic Totally Extraperitoneal Repair of Unilateral Inguinal Hernias: A Randomized Double-Blind Placebo-Controlled Trial

The potential analgesic benefit of infiltration of the wounds and extraperitoneal space with local anesthetic in patients undergoing laparoscopic totally extraperitoneal (TEP) repair of inguinal hernias remains unclear. Consenting adults scheduled to undergo laparoscopic TEP repair of unilateral inguinal hernias were recruited to this randomized double-blind placebo-controlled clinical trial of 0.25% bupivacaine (Group I) versus saline (Group II) infiltration of abdominal wounds and the extraperitoneal space. Pain scores were assessed at 4 and 24 hours postoperatively using the short-form McGill pain questionnaire (SF-MPQ), the Present Pain Index (PPI) score and the visual analogue scale (VAS). The intravenous and oral analgesic requirements were recorded. Each patient completed questionnaire to assess their satisfaction with the postoperative analgesia. 40 patients were randomized (Group I, n = 20; Group II, n = 20). The two groups were comparable for age, gender, body mass index, and operating time. Minor complications occurred in one patient in each group. There were no significant differences in the postoperative SF-MPQ scores, PPI and VAS at 4 hours (p = 0.413, p = 0.631, p = 0.615 respectively) and 24 hours (p = 0.116, p = 0.310, p = 0.100 respectively) post-operatively. The parenteral and oral analgesics consumed post-surgery were comparable (p = 0.605, p = 0.235). No difference was ob-served in the patient satisfaction scores. Infiltration of abdominal wounds and extraperitoneal space with bupivacaine in patients undergoing laparoscopic TEP repair of unilateral inguinal hernias does not appear to offer analgesic benefits.Key words: Laparoscopic; extraperitoneal; inguinal hernia; repair; pain; bupivacaine; analgesia; satisfaction; day case; randomized.

Thoracic Surgical Operations Performed under Local Anesthesia and Sedation for Diagnosis and Treatment

Generally, the operative procedures for the diagnosis or treatment of mediastinal, intrathoracic and/or chest wall lesions requiring rib resection are performed under general anesthesia. Although evidence suggests that thoracoscopy can be performed under local anesthesia, no report has indicated that some major thoracic procedures can be accomplished without general anesthesia. In our study, we advocate that certain surgical procedures could be performed under local anesthesia with a performance similar to that of general anesthesia. Thirty patients underwent thoracic procedures with local anesthesia and sedation for diagnosis and treatment. Seventeen of the patients were men, and the mean age of the patients was 49.6 years (range 16 to 71 years). There were 13 diagnostic procedures, and 17 procedures were for treatment purposes. The operative procedures performed using only local anesthesia were mini-thoracotomy (n = 9), mediastinotomy (n = 4), revision of a full-thickness posterolateral thoracic incision (n = 7), resection of the chondroma (n = 4), Eloesser flap (n = 1), metastasectomy of the chest wall (n = 3), empyectomy (n = 1), and video-assisted thoracoscopy (n = 2). Severity of pain was evaluated by VAS. There were no oral or intravenous analgesic requirements in the early postoperative period. No complications attributable to the procedure were observed. Thoracic surgical procedures for diagnosis and treatment performed under local anesthesia are simple, effective, economical and comfortable for the patient.

A comparative study of laparoscopic with conventional open donor nephrectomy in renal transplantation

Background: Laparoscopic donor nephrectomy (LDN) has been gaining popularity among kidney donors. There have been concerns about the safety and efficacy of the procedure as compared to open donor nephrectomy (ODN). We compare our results on LDN with ODN. Methods: We retrospectively analysed our data of LDN and ODN. Duration of surgery, blood loss, period of hospitalisation, per oral intake and analgesic requirements. Result: 22 LDNs were done, the operation time ranged from 220-300 minutes, and blood loss from 100–150ml. In the first 10 laparoscopic operations four cases required conversion to open surgical dissection. Only one case was converted to open surgery in the subsequent 12 laparoscopic cases. Oral intake was started on the first postoperative day. Analgesic requirement in laparoscopy cases was less. Patients were mobilised on the first day after surgery. Patients were discharged by seventh day.There was no significant difference in the functioning of the graft after revascularisation in the recipient. Conclusion: Laparoscopic donor nephrectomy is a safe and effective technique of donor nephrectomy.

Suprarrenalectomía laparoscópica retroperitoneal como opción minimamente invasiva en el tratamiento de tumores adrenales

The excision of the adrenal gland by laparoscopic approach is the gold standard for the treatment of adrenal tumors smaller than 6 cm. Most Brazilian centres favour the transperitoneal approach. The objective of the present prospective study was to show the intraoperative and postoperative results of patients undergoing adrenal laparoscopic surgery through a lateral retroperitoneal approach performed by an individual surgeon. Between January 2000 and October 2004, 35 patients (16 males and 19 females) with adrenal lesions, including 4 Cushing's syndrome, 4 Conn's syndrome, 1 neuroganglioma, 4 pheochromocytoma, 17 nonfunctioning adenomas, 1 virilizing tumor, and 4 cases of adrenal nodule after treatment of a non-adrenal primary neoplasia, prospectively underwent retroperitoneoscopic adenomectomy by one surgeon. We describe surgical times, estimated blood losses, time to oral intake, analgesic requirements, surgical complications and conversion rates, hospital stay and time to return to usual activities, comparing our results with other series in the literature. All procedures were successfully completed. Mean surgical time was 135 minutes, mean estimated blood loss 235 ml, mean time to oral intake 12 hours, no patient required analgesics after the second postoperative day, mean hospital stay was 2 days, and mean time to return to usual life activities 3 weeks. There were two complications, one case of intraoperative hypercapnia and one case with postoperative pneumonia. Conversion to open surgery was not required in any case. Retroperitoneoscopic adrenalectomy may be performed effectively and safely, with a low complication rate, independently of the etiology of the lesion. The lateral retroperitoneoscopic access is an excellent option for the minimally invasive treatment of the adrenal glands.

Stapled Hemorrhoidopexy vs. Harmonic Scalpel™ Hemorrhoidectomy: A Randomized Trial

A randomized trial was undertaken to evaluate and compare stapled hemorrhoidopexy with excisional hemorrhoidectomy in which the Harmonic Scalpel was used. Patients with Grade III hemorrhoids who were employed during the trial period were recruited and randomized into two groups: (1) Harmonic Scalpel hemorrhoidectomy, and (2) stapled hemorrhoidopexy. All operations were performed by a single surgeon. In the stapled group, the doughnut obtained was sent for histopathologic examination to determine whether smooth muscles were included in the specimen. Operative data and complications were recorded, and patients were followed up through a structured pro forma protocol. An independent assessor was assigned to obtain postoperative pain scores and satisfaction scores at six-month follow-up. Patients were also administered a simple questionnaire at follow-up to assess continence functions. Over a 20-month period, 88 patients were recruited. The two groups were matched for age and gender distribution. No significant difference was identified between the two groups in terms of operation time, blood loss, day of first bowel movement after surgery, and complication rates. Despite a similar parenteral and oral analgesic requirement, the stapled group had a significantly better pain score (P = 0.002); these patients also had a significantly shorter length of stay (P = 0.02), and on average resumed work nine days earlier than the group treated with the Harmonic Scalpel (6.7 vs. 15.6, P = 0.002). Although 88 percent of doughnuts obtained in the stapled group contained some smooth muscle fibers, no association was found between smooth muscle incorporation and postoperative continence function, and as a whole the continence outcomes of the stapled group were similar to those after Harmonic Scalpel hemorrhoidectomy. Finally, at six-month follow-up, patients who underwent the stapled procedure had significantly better satisfaction scores (P = 0.001). Stapled hemorrhoidopexy is a safe and effective procedure for Grade III hemorrhoidal disease. Patients derive greater short-term benefits of reduced pain, shorter length of stay, and earlier resumption to work. Long-term follow-up is necessary to determine whether these initial results are lasting.

A Double-Blind, Randomized Trial Comparing LigasureTM and Harmonic ScalpelTM Hemorrhoidectomy

The major problem after hemorrhoidectomy is postoperative pain. New techniques have been evolved to circumvent this problem. The present study was conducted to compare the outcomes of Ligasure hemorrhoidectomy and Harmonic Scalpel hemorrhoidectomy. This study was a double-blind, randomized controlled trial. Patients with Grade 3 and 4 hemorrhoids admitted for hemorrhoidectomy were selected and randomized into two groups: 1) Ligasure hemorrhoidectomy or 2) Harmonic Scalpel hemorrhoidectomy. The primary outcomes measured were the analgesic requirement and the postoperative pain score (assessed by an independent assessor). Secondary outcome criteria included the operating time, blood loss, hospital stay, patient satisfaction score, and early and late complications. Forty-nine patients were randomized into two groups (LigaSure 24, Harmonic Scalpel 25). Two patients were lost to follow-up, leaving 47 patients (LigaSure 24, Harmonic Scalpel 23) available for final analysis. The age and gender distribution were comparable. The postoperative pain score (median 2.6 vs. 4.8, P < 0.001) and postoperative oral analgesic (Dologesic) requirement (median 5 vs. 13, P = 0.001) were significantly less in the LigaSure group. The operating time (median 11 vs. 18 minutes, P < 0.001) was significantly less in the LigaSure group. The hospital stay, patient satisfaction score, percentage of patients requiring pethidine injection, percentage of patients with first bowel movement on or before the first postoperative day, and complication rates were similar between the two groups. Ligasure hemorrhoidectomy reduces the postoperative pain and operating time compared to the Harmonic Scalpel hemorrhoidectomy. It is a safe, effective procedure for treating Grade 3 and 4 hemorrhoids.